Scope of Practice (Provider's specialty)

Legacy Identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

#

Identifier

Identifier Type

Identifier State

Identifier Issuer

1

0553891

MEDICAID

NJ

Proprietary Identifiers Ever Reported

#

Identifier

Identifier Type

Identifier State

Identifier Issuer

1

0553891

MEDICAID

NJ

NPI Data Dissemination. Special Note for Health Care Providers.

In September 2007, CMS began disclosing NPPES health care provider data that are disclosable under the Freedom of Information Act (FOIA) to the public.
The FOIA-disclosable data for a health care provider (individual or organization) who deactivated an NPI will now be disclosed within the files. For a deactivated NPI, CMS will only disclose the deactivated NPI and the associated date of deactivation within the files.

The NPI Registry and the downloadable files will contain data from the NPPES as reported to NPPES by you, or by someone acting on your behalf, or by an organization provider's Authorized Official.
If the downloadable file or the NPI Registry reflects information that is incorrect, health care providers should correct that information.

At any time, providers, or someone acting on their behalf, may edit their records by going to https://nppes.cms.hhs.gov, or by obtaining a paper NPI Application/Update Form (CMS-10114) from the NPI Enumerator or from the CMS forms page (http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms) and mailing the completed, signed form to the NPI Enumerator. Providers who need assistance in editing their records should contact the NPI Enumerator by phone at 1-800-465-3203, by email customerservice@npienumerator.com, or by letter: NPI Enumerator, P.O. Box 6059, Fargo, ND 58108-6059.

The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. An Employer Identification Number (EIN) is assigned by the Internal Revenue Service (IRS) to identify a business entity. It may or may not be that business entity's Taxpayer Identification Number (TIN). An SSN should not be entered in the EIN field.

4

Is Organization Subpart

N

The "Is the organization a subpart?" question must be answered. If the organization is a subpart, the Parent Organization Legal Business Name (LBN) and Parent Organization Taxpayer Identification Number (TIN) fields must be completed. The Parent Organization LBN and TIN fields can only be completed if the answer to the subpart question is Yes.
Many organization health care providers who apply for NPIs are not legal entities themselves but are parts of other organization health care providers that are legal entities (the "parents").
Here are three examples of organization health care providers that may be considered subparts and may apply for NPIs if so directed by their "parents":
(1) The psychiatric unit in a hospital is not a legal entity but is part of the hospital (the "parent"), which is a legal entity. The legal entity must obtain an NPI. The psychiatric unit is an example of a subpart that could have its own NPI if the hospital determines that it should.
(2) A group practice that is not a sole proprietorship has a main location and could have other offices in different locations, but each office is not a separate legal entity; instead, each office is part of the corporation (the "parent") which is a legal entity. The offices are examples of subparts that could have their own NPIs if the main location determines that they should.
(3) A pharmacy fills prescriptions for patients whose physicians have prescribed medications for them and may also rent or sell durable medical equipment to patients whose physicians have ordered such equipment for them. Neither the pharmacy line of business nor the DME line of business represent legal entities; instead, both lines of business are part of an organization (the "parent") that is a legal entity. Each line of business represents a different Healthcare Provider Taxonomy or area of specialization that often submits its own electronic claims to health plans.
The "parent"-we don't know who the parent is in this example-must ensure that each subpart that submits its own claims to health plans has its own NPI.

5

Provider Organization Name (Legal Business Name)

CENTER FOR HUMANISTIC CHANGE OF NJ, INC.

Provide organization name (legal business name used to file tax returns with the IRS). The Organization Name field allows the following special characters: ampersand, apostrophe, "at" sign, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.

6

Provider First Line Business Mailing Address

12 US HIGHWAY 206

The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''.

7

Provider Business Mailing Address City Name

STANHOPE

The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''.

8

Provider Business Mailing Address State Name

NJ

The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''.

9

Provider Business Mailing Address Postal Code

07874-3269

The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''.

10

Provider Business Mailing Address Country Code

US

The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''.

11

Provider Business Mailing Address Telephone Number

973-691-3488

The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''.

12

Provider Business Mailing Address Fax Number

973-691-2797

The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address fax number''.

13

Provider First Line Business Practice Location Address

48 GREEN APPLE RD

The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.

14

Provider Business Practice Location Address City Name

SPARTA

The city name in the location address of the provider being identified.

15

Provider Business Practice Location Address State Name

NJ

The State or Province name in the location address of the provider being identified.

16

Provider Business Practice Location Address Postal Code

07871-2727

The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.

17

Provider Business Practice Location Address Country Code

US

The country code in the location address of the provider being identified.

18

Provider Business Practice Location Address Telephone Number

973-729-4595

The telephone number associated with the location address of the provider being identified.

19

Provider Enumeration Date

04/24/2017

The date the provider was assigned a unique identifier (assigned an NPI).

20

Last Update Date

04/24/2017

The date that a record was last updated or changed.

21

Authorized Official Last Name

KUCINSKI

The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.

22

Authorized Official First Name

PAUL

The first name of the authorized official

23

Authorized Official Middle Name

STEVEN

The middle name of the authorized official

24

Authorized Official Title or Position

ASSOCIATE EXECUTIVE DIRECTOR

The title or position of the authorized official

25

Authorized Official Name Prefix Text

MR.

Authorized Official Name Prefix Text

26

Authorized Official Telephone Number

973-691-3488

The 10-position telephone number of the authorized official.

27

Healthcare Provider Taxonomy Code #1

320900000X

The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.

Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.

30

Provider License Number State Code 1

NJ

Provider License Number State Code #1

31

Healthcare Provider Primary Taxonomy Switch 1

Y

Primary Taxonomy:

X - The primary taxonomy switch is Not Answered;

Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);

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